拮抗剂方案在卵巢储备功能低下患者中的临床应用及费效比

Clinical application and economic analysis of gonadotropin-releasing hormone antagonist protocol in patients with decreased ovarian reserve

目的探讨拮抗剂方案在卵巢储备功能低下(DOR)患者中的临床应用和费效比。方法回顾性病例对照研究分析2014年10月—2016年10月期间在我院接受体外受精-胚胎移植(IVF-ET)治疗的DOR患者,按年龄分层随机抽取DOR患者302例,将其分为<35岁组(153例)及≥35岁组(149例),再将<35岁组分为3小组,其中拮抗剂方案62例(A组),超长方案43例(B组),微刺激方案48例(C组);≥35岁组也分为3小组,拮抗剂方案45例(D组),微刺激方案48例(E组),拮抗剂联合温和刺激方案组56例(F组)。比较不同年龄段DOR患者拮抗剂方案与其它控制性超促排卵(COH)方案的临床结局及费效比。结果在<35岁的DOR患者中,新鲜胚胎移植临床妊娠率B组(41.93%)高于A组(33.33%)及C组(25.00%)(P<0.05);累积临床妊娠率和累积活产率A组(66.13%,56.45%)优于B组(51.17%,46.51%)及C组(43.75%,39.58%)(P<0.05);每一启动周期总费用以C组[(23 563±2 133)元]最低(P<0.05),但每获一成熟卵子所需费用、每获一枚优质胚胎所需费用及每获一活产所需费用A组较B组及C组低(P<0.05);≥35岁DOR患者中,累积临床妊娠率、累积活产率方面,E组(33.33%,25.00%)低于D组(44.44%,35.56%)及F组(46.42%,39.29%)(P<0.05),D组与F组相近(P>0.05);每一启动周期总费用以E组[(19 311±2 238)元]最低,但每获一成熟卵子所需费用、每获一枚优质胚胎所需费用及每获一活产所需费用F组最低(P<0.05)。结论在<35岁的DOR患者中,从临床结局及费效比方面综合考虑,拮抗剂方案是比较理想的COH方案;在≥35岁患者中,拮抗剂联合温和刺激方案可以获得理想的临床结局和费效比。

Objective To investigate the clinical application and cost effectiveness of gonadotropin- releasing hormone antagonist （GnRH-A） protocol in the patients with decreased ovarian reserve （DOR）. Methods A retrospective analysis of clinical outcomes and costs was performed in 302 infertile patients with DOR after in vitro fertilization-embryo transfer （IVF-ET） in our hospital from October 2014 to October 2016. According to different ages, patients were divided into 〈35 years old group （153 cases） and ~ 35 years old group （149 cases）. And according to the different protocol, 〈35 years old group was divided into 3 groups, which included 62 cycles of GnRH-A protocol （group A）, 43 cycles of ultra-long protocol （group B）, 48 cycles of minimal ovarian stimulation protocol （group C）, and ~ 35 years old group was divided into 3 groups, which included 45 cycles of GnRH-A protocol （group D）, 48 cycles of minimal ovarian stimulation protocol （group E）, 56 cycles of mild stimulation protocol with GnRH-A （group F）, clinical outcomes and the cost-effective ratio were compared between GnRH-A protocol and other protocols. Results In the patients 〈35 years old with DOR, the clinical pregnancy rate of fresh embryo transplantation in group B was the highest than that in the other two groups （P〈0.05）, the cumulative pregnancy rate and the cumulative live birth rate were the highest in group A （66.13%, 56.45%） than in groups B （51.17%, 46.51%） and C （43.75%, 39.58%） （P〈0.05）. Total cost per start-up cycle was the lowest in group C than that in the other two groups （P〈0.05）, but other economic indicators including the each mature eggs cost and the each good embryo cost and the each live birth cost were the lowest in group A （P〈0.05）. In the patients 〉/35 years of DOR, the cumulative pregnancy rate and the cumulative live the yield were the lowest in group E （33.33%,25.00%） than in group D （44.44%, 35.56%） and group F （46.42%, 39.29%） （P〈0.05）, while those indicators in the group D were similar to group F （P〉0.05）. These economic indicators including the each mature eggs cost, the each good embryo cost and the each live birth cost were the lowest in group F （P〈0.05）. Conclusion The GnRH-A protocol was an ideal solution in less than 35 years patients with DOR; the mild stimulation protocol with GnRH-A was better than the other protocols in more than 35 years patients with DOR.